# NTSB ERA16LA183: Piper PA 22, N5823Z, Gallatin, TN, May 13, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 13, 2016, 14:30 local (19:30 UTC) - Place: Gallatin, TN - Coordinates: 36.373332, -86.408332 - Nearby events: https://openairdocs.org/map.md?lat=36.3733&lon=-86.4083&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report January 26, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA-FSDO - NTSB case key (mKey): 93167 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA183 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93167/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93167 - Page: https://openairdocs.org/ntsb/ERA16LA183 ## Probable cause The pilot's inadequate preflight inspection, which resulted in an inflight fire due to the presence of a bird nest in the engine compartment. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-22-108, 2 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7102204), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Piper PA-22-108, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=7102204), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Initial climb: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Piper PA-22-108, 2 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=7102204), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-22-108, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102204), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Piper PA-22-108, 11 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102204), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis During preflight inspection of the airplane, the pilot discovered three baby birds in the cockpit. After removing the birds, he continued his preflight inspection, looking for a nest. He noticed that the rag normally used to cover one of the elevator openings was missing, but he did not find a nest inside. Immediately after takeoff, about 100 ft above ground level, a fire started within the engine compartment, and smoke began to enter the cockpit. The pilot turned the airplane back toward the runway, but lost control as the airplane touched down because his visibility was limited by the smoke. The occupants egressed the airplane, which was subsequently consumed by fire. Postaccident examination of the wreckage revealed remnants of a bird nest between the exhaust manifold and the engine firewall, which was the likely origin of the fire. ## Factual narrative On May 13, 2016, about 1430 central daylight time, a Piper PA-22, N5823Z, was substantially damaged during an emergency landing at Sumner County Regional Airport (M33) Gallatin, Tennessee. The private pilot and two passengers were uninjured. The airplane was privately owned and operated. Visual meteorological conditions prevailed and no flight plan was filed for the local, personal flight that was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot stated that when he arrived at the airplane to conduct his preflight inspection, the cockpit area contained "three live baby birds." He did not see any sign of a nest, but did notice that one of the elevator openings was not covered up by a rag that he placed in the opening several months before. He resumed his preflight inspection and did not see any additional evidence of bird activity or a nest. After engine start and a 5-minute taxi, he departed runway 35. During the initial climb, about 100 feet above ground level, black smoke started pouring out of the left side rudder area. The pilot attempted to make a 180-degree steep turn back to runway 17. During the turn, fire emanated out of the left side of the rudder pedal area. The pilot stated he attempted to stomp out the fire near his left foot but was unable to extinguish the blaze. The cockpit filled with smoke and limited ability to see the runway. He touched down at an airspeed between 30 and 40 knots but could not see the runway. A witness reported that after touching down on the runway, the airplane's "tail started going back and forth." The airplane bounced several times, swerved and departed the right side of the paved surface of the runway and nosed over into the grass, approximately two-thirds of the way down the runway. After it came to rest, the passengers and pilot evacuated before the airplane became engulfed in flames. According to the pilot and Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with a rating for airplane single-engine land. The pilot reported 959 total hours of flight experience, and 159 of those hours where in the accident airplane make and model. According to FAA and airplane maintenance records, an annual inspection was completed on September 1, 2015 and at that time the airframe had accumulated 4,013 total hours. The airplane came to rest on its nose, about 45 degrees nose down, approximately 3,700 feet down runway 17, and 6 feet off the paved surface. Both propeller blades exhibited chordwise scraping and were curled aft. The engine compartment was fire-damaged, with the most severe damage located aft of the engine near the firewall. The fire propagated aft from the engine compartment, through the cockpit and to the left wing, fuselage and tail. The right wing and right elevator remained covered with fabric and remained largely intact. An exterior examination of the engine revealed remnants of a bird nest between the top of the exhaustmanifold and the firewall. No other abnormalities were noted. ## Aircraft - Registration: [N5823Z](https://openairdocs.org/deregistered/N5823Z-2018-03-30), registration cancelled 2018-03-30, S/N 22-9680, built 1963 (OpenAirDocs) - Reported make and model: PIPER PA 22 (108) - Registry model: [Piper PA-22-108](https://openairdocs.org/model/piper-pa-22-108) (registry code 7102204) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 22-9680 - Year built: 1963 - Airframe hours: 4013.75 - Engines: LYCOMING O-235 108 horsepower reciprocating - Damage: Substantial damage - Fire: In-Flight - Flight: Personal, Part 91 - Operator: Harms Gregory F - Registered owner: Harms Gregory F - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 1, 2015 - Departed: M33, Gallatin, TN - Destination: M33, Gallatin, TN - Airport: M33, Sumner County Rgnl, runway 17, 6,300 × 100 ft, asphalt - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3; last flight review June 6, 2014; seat: left; restraint: lap only; flight hours: 959 total, 159 in this make and model, 959 as pilot in command, 1 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 3 knots, gusting 13 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 46 °F - Altimeter: 30.11 inHg - Observed at: M33 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20160513006699A](https://openairdocs.org/incident/20160513006699A), May 13, 2016: Piper PA-22-108, Gallatin, TN, Substantial damage. On may 13, 2106, at approximately 1420 local, N5823Z departed runway 35. Upon departure, at approximately 100 feet AGL, the PIC noticed smoke coming out of the… ## Docket (8 files) The files NTSB released with the investigation on December 2, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93167. 13.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 966 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447005&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statement (item 2, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447006&FileExtension=.PDF&FileName=Pilot%20Statement%20-Master.PDF - Record of Conversation with Pilot (item 3, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447007&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20Pilot-Master.PDF - Witness Statement (item 4, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447008&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Accident Photographs (item 5, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447009&FileExtension=.PDF&FileName=Accident%20Photographs-Master.PDF - FAA Eyewitness Telephone Statement (item 6, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447010&FileExtension=.PDF&FileName=FAA%20Eyewitness%20Telephone%20Statement-Master.PDF - Maintenance Records (item 7, .PDF, 9.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447011&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Airport Overview and Accident Location (item 8, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447012&FileExtension=.PDF&FileName=Airport%20Overview%20and%20Accident%20Location-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.